Do you set standards for the qualification and performance and/or certify your members?

Required

If "Yes", please explain

Optional

Do you engage in any disciplinary actions as a result of peer review activities?

Required

If "Yes", please explain

Optional

Do you administer or sponsor any insurance programs for your members?

Required

If "Yes", please explain

Optional

Financial Information

Previous Year

Total Assets

Required

Net Assets/Fund Balance

Required

Annual Revenue

Required

Change in Net Assets (Excess/Deficit)

Required

Current Year

Total Assets

Required

Net Assets/Fund Balance

Required

Annual Revenue

Required

Change in net Assets (Excess/Deficit)

Required

Please upload the most recent annual financial audit or 990 form.

Required

Directors & Officers

Directors and Officers Liability Insurance has been continuously in force since

Required

Within the last 5 years, has any claim or suit been made against a Director, Officer, Employee, or Volunteer?

Required

Are you aware of any fact, circumstance or situation which may result in a claim?

Required

Do you provide services for persons under the age of 18?

Required

Employment Practices Liability

Employment Practices Liability Insurance has been continuously in force since

Required

# of Employees 1 Year Ago

Full Time

Required

Part Time

Required

Temporary

Required

Leased

Required

Non U.S. based employees/volunteers

Required

Total Sum

Required

# of Employees Currently

Full Time

Required

Part Time

Required

Temporary

Required

Leased

Required

Non U.S. based employees/volunteers

Required

Total Sum

Required

How many employees have been terminated in the past 12 months?

Required

How many employees have been demoted in the past 12 months?

Required

How many employees will be terminated in the next 12 months?

Required

How many employees will be demoted in the next 12 months?

Required

Do you have an employement handbook?

Required

Do you use an employment application for every potential employee?

Required

Do you have an "At Will" provision in the employment application or handbook?

Required

Have you implemented an anti-sexual harassment policy?

Required

Do you use outside employment counsel for employment advise?

Required

Optional Coverages

Is Workplace Violence coverage desired?

Optional

Is Internet Liability desired?

Optional

Additional Information

How did you hear about us?

Required

Submission Validation

Required

Enter the Validation Code from above.

Important NoticeAny
submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
contact us.